BSc(Hons)

Occupational Therapy

Research Report:
Literature Review

Module UZYYAC-30-3

Submitted by: Au Wing Nam

Cohort: 2022 Submission Date: 2/5/2025

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 School of Health and Social Wellbeing
College of Health, Science and Society

Declaration form
Name of student: Au Wing Nam

Dissertation title: How effective is the use of Cognitive Orientation to

Daily Occupational Performance approach in improving

occupational performance and quality of life in adults with

neurological conditions?

Programme: BSc (Hons) Occupational Therapy

This study was undertaken as an individual project. I declare that I am

the sole author of this report.

Literature sources and any research collaborators have been identified

and acknowledged.

I declare that the work has not already been accepted in substance for
any degree and is not concurrently submitted in candidature for any
degree.

Signature AU WING NAM

Date 1/4/2025

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 School of Health and Social Wellbeing
College of Health, Science and Society
Name: Au Wing Nam

Student Number: 22033837

Title: How effective is the use of Cognitive

Orientation to Daily Occupational Performance

approach in improving occupational

performance and quality of life in adults with

neurological conditions?

UNIVERSITY OF THE WEST OF ENGLAND

BSc (Hons)
OCCUPATIONAL THERAPY

Word Count: 6

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Acknowledgements

First and foremost, I would like to express my deepest gratitude to my parents and

my partner for their unwavering love, support, and encouragement throughout my

academic journey. Without their sacrifices and belief in me, this achievement would

not have been possible.

I am also immensely grateful to my professors for their invaluable guidance,

patience, and expertise, which have shaped my research and growth as a scholar.

To my dear friends—thank you for the laughter, motivation, and companionship

during both the challenging and rewarding moments. Your presence has meant more

than words can convey.

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Abstract

Background

Neurological conditions often impair cognitive and motor function, diminishing

individuals’ ability to perform daily activities and reducing independence. The
Cognitive Orientation to Daily Occupational Performance, a client-centred approach,
targets cognitive strategies to improve functional performance, yet its efficacy in
Parkinson’s disease remains underexplored. The aim of this study is to evaluate
Cognitive Orientation to Daily Occupational Performance’s impact on occupational
performance and quality of life in adults with neurological conditions.

Method

A literature review was undertaken. Five studies were selected using systematic
search strategy and were critically appraised.

Findings
Four themes emerged: (1) Effectiveness of the Approach; (2) Personalisation of
Intervention; and (3) Challenges and Barriers to Implementation. These findings
provide a comprehensive understanding of CO-OP’s impact in adult
neurorehabilitation.

Outcome

CO-OP demonstrated short-term functional benefits for adults with neurological

conditions, but sustainability and scalability remain limited, indicating the need for
broader integration strategies and long-term research.

Content
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s
1. Introduction........................................................................................................8
1.1 Problem Statement..........................................................................................8
1.2 Reflexivity.........................................................................................................9
1.3 Rationale........................................................................................................ 10
1.4 Key Terms...................................................................................................... 10
1.5 Research Aims and Question.......................................................................10
2. Methodology.....................................................................................................12
2.1 Research Design........................................................................................... 12
2.2 Search Strategy............................................................................................. 13
2.3 Inclusion and Exclusion Criteria..................................................................15
2.4 Critical Appraisal...........................................................................................16
2.5 Generation of Themes...................................................................................16
2.6 Ethical Considerations..................................................................................17
3. Findings............................................................................................................18
3.1 Overview of Data........................................................................................18
3.2 Narrative Explanation of Results..............................................................29
3.3 Thematic Analysis.....................................................................................30
4: Discussion...........................................................................................................31
4.1 Interpretation of Findings.............................................................................31
4.2 Limitations..................................................................................................... 31
4.3 Implications....................................................................................................31
5: Conclusion.......................................................................................................... 32
References...............................................................................................................32

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List of Tables and Figure

Table 1: Electronic databases………………………………………………………...

Table 2: Search terms………………………………………………………...
Table 3: Inclusion and exclusion criteria……………………………………
Table 4: Taheri et al. (2023)…………………………………………………….
Table 5: Davies et al. (2025)………………………………………………………
Table 6: Wolf et al. (2016)……………………………………………………..
Table 7: Saeidi Borujeni et al. (2023)…………………………………………
Table 8: Ahn et al. (2017)………………………………………………………………

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1. Introduction

Neurological conditions, disorders affecting the brain, spinal cord, or peripheral

nerves, such as Parkinson’s disease (PD), stroke, multiple sclerosis (MS), and
traumatic brain injury (TBI), are characterised by progressive deterioration of motor
function and cognition (Cleveland Clinic, n.d.). These conditions often disrupt an
individual’s ability to engage in meaningful daily activities, leading to reduced
independence, diminished quality of life (QoL), and increased reliance on caregivers
(Aragon and Kings, 2018; Tramonti et al., 2018). Neurological conditions represent a
significant and growing global health challenge, affecting approximately 1 in 3
people globally during their lifetime (WHO, 2024). Recent data reveals that
neurological disorders account for 11.1 million deaths in 2021 and contribute to 443
million disability-adjusted life years, an 18.2% increase since 1990 (Steinmetz et al.,
2024).

Occupational therapy plays a pivotal role in mitigating these challenges by enabling

individuals to engage in meaningful activities through adaptive strategies. Among
emerging interventions, the Cognitive Orientation to Daily Occupational Performance
(CO-OP) approach has garnered attention for its client-centred, cognitive-strategy-
based framework. CO-OP, rooted in cognitive-behavioural principles, focuses on
goal-setting, problem-solving, and self-monitoring to enhance task performance by
improving his/her skills and teaching problem-solving skills and task-specific
strategies in individuals with motor or cognitive impairments (NHS Physical Health
Psychology Cumbria, n.d.; Polatajko et al., 2001). Unlike traditional motor
rehabilitation, CO-OP is based on the belief that occupational performance may be
improved by boosting such cognitive skills as attention, memory, and other forms of
executive functions that are commonly deficient in neurological conditions (Polatajko
et al., 2001). As a result of promoting and strengthening cognitive strategies, CO-OP
intends to restore clients’ independence and occupational performance (Houldin et
al., 2017). CO-OP could therefore be of great use in neurological conditions in
addressing the cognitive and emotional difficulties that assail people.

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1.1 Problem Statement

Current rehabilitation approaches often focus on compensatory strategies

or pharmacological management (Belagaje MD, 2023). However, these methods fail
to address the cognitive-motor integration necessary for long-term functional
improvement (Maier, Ballester and Verschure, 2019). Levodopa and deep brain
stimulation, for instance, ameliorate motor symptoms but fail to counteract the
progressive cognitive decline that exacerbates functional limitations in PD patients
(Muthuraman et al., 2018). The CO-OP approach, grounded in cognitive-behavioural
principles, targets these gaps by fostering problem-solving, goal-setting, and self-
monitoring skills (Polatajko et al., 2001). But its adoption in neurological rehabilitation
is inconsistent due to limited high-quality evidence, variability in symptom severity,
and logistical barriers such as therapist training and resource constraints (Zaman,
Ghahari and McColl, 2021). This disparity between CO-OP’s theoretical promise and
its practical application in neurological care emphasises the necessity of a rigorous
evaluation of its efficacy, feasibility, and adaptability in this context.

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1.2 Reflexivity
The fact that I am personally interested in the utilisation of the CO-OP approach in
treating people with neurological conditions necessitates the pursuit of the question.
From the years of practice, I saw the severe difficulties that people with severe
neurological conditions encounter most essentially in their abilities to carry out
important parts of daily life affecting their freedom and QoL. A number of profession-
related experiences have given me the drive to help develop interventions to cater
for the various motor and cognitive complications that come with those conditions.
These experiences highlighted the limitations of symptom-focused interventions and
ignited my curiosity about cognitive-strategy-based approaches like CO-OP.
However, I acknowledge that my clinical experiences may introduce bias, such as
overestimating CO-OP’s applicability or underestimating implementation challenges.
To mitigate this, I adopted a systematic methodology, including rigorous literature
screening using critical appraisal tools and thematic analysis to synthesise diverse
findings impartially and ensuring that inclusion criteria were based on methodological
quality rather than alignment with my assumptions (Coughlan and Cronin, 2020).
1.3 Rationale
The rationale for this study is threefold. First, the rising prevalence of neurological
conditions demands interventions that address their multidimensional impact.
Second, CO-OP’s theoretical alignment with the cognitive-motor interplay in
neurological conditions positions it as a promising yet underutilised tool. Third,
existing literature reveals a paucity of high-quality studies evaluating CO-OP’s long-
term efficacy and feasibility in neurological conditions, limiting clinical adoption.
Clinically, this research could inform guidelines for occupational therapists,
promoting evidence-based, client-centred care and ensuring that the introduced
interventions will be sufficient to address the needs of people with neurological
conditions. From a policy perspective, demonstrating CO-OP’s cost-effectiveness
may advocate for its integration into public health strategies, particularly in resource-
limited settings. Academically, this study contributes to the broader discourse on
neurorehabilitation by elucidating how cognitive strategies can complement motor
therapies, thereby enriching OT’s theoretical foundations.

1.4 Key Terms

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Neurological conditions: Neurological conditions, disorders affecting the brain,
spinal cord, or peripheral nerves, such as PD, stroke, MS, and TBI, are
characterised by progressive deterioration of motor function and cognition
(Cleveland Clinic, n.d.).

Cognitive Orientation to Daily Occupational Performance (CO-OP): A client-

centred, evidence-based intervention approach used in occupational therapy that
focuses on skill acquisition through cognitive strategy training. It employs goal-
oriented problem-solving to help individuals with motor or cognitive impairments
improve their performance in meaningful daily activities (Polatajko et al., 2001).

Activities of Daily Living (ADLs): Essential everyday tasks that individuals need to
perform to live independently, such as dressing, bathing, eating, and mobility (AOTA,
2020). In the context of PD, these activities can become significantly impaired due to
both motor and cognitive deficits.

Occupational Therapy: A healthcare profession that assists individuals in

developing, recovering, or maintaining skills necessary for daily activities.
Occupational therapists work with clients to address physical, cognitive, and
emotional challenges to enhance overall independence and well-being (RCOT, n.d.).

Client-Centred Approach: A therapeutic model that focuses on the individual’s

preferences, needs, and goals. In occupational therapy, this approach prioritises the
active involvement of the client in setting and achieving goals to enhance functional
performance and QoL (Okita et al., 2024).

1.5 Research Aim

The aim of this study is to evaluate the efficacy of CO-OP in improving occupational
performance and QoL in people with neurological conditions through a systematic
literature review of current evidence. Specifically, the research will examine how CO-
OP interventions address both motor and cognitive deficits characteristic of
neurological conditions while assessing the long-term sustainability of treatment
benefits. Additionally, the study will identify practical implementation challenges that
may affect clinical adoption. By synthesising current evidence and analysing these

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critical factors, this research seeks to develop evidence-based recommendations
that can optimise occupational therapy practice and ultimately enhance rehabilitation
outcomes for the growing patient population.

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2. Methodology

2.1 Research Design

This study adopts a literature review methodology to address the research question.
A literature review is a robust method for systematically searching, analysing, and
synthesising existing literature on a specific topic or subject, allowing for a synthesis
of findings, the identification of knowledge gaps, and the proposal of future areas for
further research (Chigbu, Atiku and Du Plessis, 2023). Unlike primary research, this
design allows for the aggregation of findings across diverse studies like clinical trials
and systematic reviews, enabling a comprehensive analysis of CO-OP’s application
in varied neurological populations (Paré and Kitsiou, 2017). Moreover, this approach
ensures methodological transparency and rigor, as it follows structured processes for
search strategy design, critical appraisal, and thematic analysis — key components
for generating credible, evidence-based conclusions (Paré and Kitsiou, 2017).
Therefore, a literature review can help shape future research directions on the effect
of the CO-OP approach on people with neurological conditions while highlighting
gaps in current knowledge by critically evaluating diverse studies (Cronin and
George, 2020).

The research design is guided by established frameworks for synthesising evidence

in healthcare research. This design involves four interrelated phases: (1) systematic
literature search, (2) critical appraisal of included studies, (3) thematic analysis of
findings, and (4) interpretation of results within clinical and theoretical contexts (Paré
and Kitsiou, 2017). The systematic literature search is conducted using predefined
keywords and database selection criteria to ensure comprehensiveness and
minimise selection bias. Following this, each study undergoes a critical appraisal
using standardised tools such as the Critical Appraisal Skills Programme (CASP)
checklist or the Joanna Briggs Institute (JBL) checklist to assess methodological
quality and relevance (CASP, 2023; JBI, 2020). Central to the design is the use of
thematic analysis, a method adapted from Braun and Clarke’s framework (2006),
which identifies recurring patterns and themes across studies to construct a
comprehensive understanding of CO-OP’s impact. Thematic analysis is particularly
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valuable in occupational therapy research, as it allows for the synthesis of both
qualitative and quantitative findings, providing a holistic view of the intervention’s
effectiveness, challenges, and practical applications (Dixon-Woods et al.,
2005). Finally, in order to ensure that the conclusions drawn are both clinically
meaningful and theoretically grounded, the synthesised findings are critically
interpreted within the broader context of occupational therapy theory and practice.

Literature reviews mitigate selection bias by adhering to predefined search protocols

and inclusion criteria so that the findings are credible, balanced, and representative
of the existing evidence (NHMRC, 2019).

2.2 Search Strategy

A systematic search strategy was used to ensure comprehensive, unbiased literature

coverage and methodological transparency, which strengthens the validity and
reproducibility of the review's conclusions (Coughlan and Cronin, 2020). The
approach towards searching the literature relevant to the study was to use electronic
databases, as these databases contain the maximum number of medical and health
care-related articles. These databases guarantee using sources from reputable,
peer-reviewed publications only. In addition to database searches, a general Google
Scholar search was conducted to broaden the review’s scope.

Table 1: Electronic databases

Database Justification

AMED Included as it specialises in allied health and rehabilitation

research, particularly relevant to occupational therapy
interventions
PubMed Selected for its comprehensive coverage of biomedical
literature, including occupational therapy and neurology
research
SAGE Journals Chosen for its strong collection of peer-reviewed
healthcare journals

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 Scopus Strong coverage of international rehabilitation research and
robust citation tracking features

Search terms were framed using the PICO framework to identify key elements to
search for relevant studies: P = population (people with neurological conditions); I =
intervention (CO-OP approach); C = comparison (none); O = outcome (occupational
performance, QoL). Many of the strategies, for example, Boolean operators
(AND/OR/NOT), filtered irrelevant articles, whereas truncation (e.g., occupational
therap*) captured more relevant variants by replacing specific characters with
asterisks and extended the search outcomes by including synonyms (The University
of Edinburgh, 2024).

Table 2: Search terms

Concept Search Term Variants

Neurological Conditions - "neurological disorder*" OR "neurological
disease*" OR "neurological condition*"
- "Parkinson* disease" OR PD OR
"Parkinson*"
- "multiple sclerosis" OR MS
- "stroke" OR CVA OR "cerebrovascular
accident"
- "traumatic brain injury" OR TBI
CO-OP approach
- "Cognitive Orientation to Daily
Occupational Performance" OR "CO-OP"
- "cognitive strategy training"
Population - adult* OR "older adult*" OR "middle aged"
- patient* OR client* OR participant* OR
individual*
Intervention - therap* OR treatment* OR intervention* OR
trial* OR rehabilitat*
- "occupational therap*" OR OT
- cogniti* strateg* OR problem-solv*
Outcomes - "activities of daily living" OR ADL* OR
"instrumental ADL" OR IADL
- "quality of life" OR QoL
- "occupational performance"

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 Combined search string (("Cognitive Orientation to Daily Occupational
Performance" OR "CO-OP" OR "cognitive
strategy training")
AND
("neurological disorder*" OR "Parkinson* disease"
OR "multiple sclerosis" OR stroke OR "traumatic
brain injury")
AND
(adult* OR "older adult*")
AND
("occupational therap*" OR rehabilitation)
AND
("activities of daily living" OR "quality of life" OR
"occupational performance")
NOT
(child* OR pediatric OR paediatric))

2.3 Inclusion and Exclusion Criteria

Inclusion and exclusion criteria were rigorously applied to ensure the selected
studies were methodologically robust and directly relevant to the research aims.

Table 3: Inclusion and exclusion criteria

Category Inclusion Criteria Exclusion Criteria Justification

Publication 2014-2025 Pre-2014 To ensure the evidence reflects
Date publications the most recent and relevant
clinical practices and research
trends
Intervention Studies explicitly Non-CO-OP To directly address the research
using CO-OP interventions (e.g., question concerning the
approach drug trials, application of the CO-OP
physical therapy approach in this population
alone)
Outcomes Measures Studies without Aligns with research's aim to
occupational functional outcome assess CO-OP's impact on daily
performance, measures functioning

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 ADLs, or QoL
Publication Peer-reviewed, Preprints, non- Ensures quality control through
full-text articles peer-reviewed academic peer-review process
manuscripts
Language English-language Non-English Ensures accurate interpretation
publications publications of results given resource
constraints

2.4 Critical Appraisal

In order to ensure validity, reliability, and trustworthiness, scrutiny of study

methodologies and adherence to research standards are vitally important (Coughlan
and Cronin, 2021). The methodological quality of included studies was assessed
using critical appraisal tools relevant to the research design to evaluate bias, validity,
and applicability (Coughlan and Cronin, 2021). This process ensured only high-
quality evidence informed the synthesis, reducing the risk of conflating biased or
underpowered findings. The CASP RCT (2023) checklist was used to appraise
Davies et al. (2025), Wolf et al. (2016) and Ahn et al. (2017). The JBL checklist
(2020) for quasi-experimental studies was used to appraise Saeidi Borujeni et al.
(2023). The CASP systematic review checklist (2023) was used to appraise Taheri
et al. (2023).

2.5 Generation of Themes

After appraising study quality, data extraction focused on capturing participant

characteristics, intervention parameters, outcome measures, and reported
experiences. Thematic analysis was conducted following Braun and Clarke’s six-
phase framework (2006): familiarisation with data, initial coding, theme development,
theme review, theme definition, and report production. This process began with
comprehensive familiarisation through repeated reading of all selected articles to
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identify key concepts and preliminary codes. During coding, each sentence or
paragraph reporting on CO-OP’s effects, barriers, or contextual factors was
systematically labelled with descriptive codes. Subsequently, similar codes were
clustered into candidate themes such as “enhanced task competence” or “training
barriers”. These themes underwent iterative refinement to ensure they were
internally coherent and distinct from each other. This analytical rigor ensured the
themes were firmly grounded in the empirical evidence while allowing for meaningful
theoretical contributions to occupational therapy practice for neurorehabilitation.

2.6 Ethical Considerations

Research ethics refers to the set of ethical principles and guidelines that govern the
conduct of research involving human participants, animals, groups, and entire
societies (Bos, 2020). As a literature review, ethical considerations centred on
intellectual integrity and adherence to academic standards. All included studies were
evaluated for ethical compliance, including informed consent procedures,
confidentiality protections, and avoidance of harm to participants (Resnik, 2020).
Particular attention was given to studies involving vulnerable neurological
populations to make sure their rights and dignity were upheld throughout the original
research processes (Oates, 2021). Originality and plagiarism were avoided through
meticulous paraphrasing and citation using UWE Bristol Harvard referencing.
Potential biases, such as the researcher’s clinical inclination toward CO-OP, were
mitigated through reflexivity.

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3 Findings

3.1 Overview of Data

The tables below summarise key details from the five selected studies in terms of
their objectives, methodologies, significant findings, strengths, limitations and
relevance to the research question.

Table 4: Taheri et al. (2023)

Title
Effectiveness of Cognitive Orientation to Daily Occupational Performance in
Parkinson’s Disease: A Case Report

Method
Quantitative single-case study

Aim
To determine the effectiveness of the CO-OP approach on perceived satisfaction and
occupational performance in a 62-year-old woman with PD

Sample
62-year-old woman with PD (Hoehn & Yahr stage 3), moderate cognitive impairment,
and depression

Interventions & Duration

- 12 sessions (twice weekly) over 6 weeks
- Focused on three client-selected goals (wearing scarf, working with phone, and
cooking)
- Utilised the Goal-Plan-Do-Check strategy in conjunction with CO-OP

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 Findings
- COPM: Improved performance (e.g., cooking from 2 to 7) and satisfaction post-
intervention
- Functional independence measure (FIM): Increased from 90 (minimal assistance) to
105 (supervision only) post-intervention
- These gains were not fully sustained at follow-up, as evidenced by the cooking
score declining to 3
- No changes were observed in cognitive function (MoCA) or depression severity
(BDI-II)

Strengths
- Ethical approved document
- Informed consent obtained; participant rights protected
- Exemplifies transparency through detailed documentation of the participant’s
medical history, home environment, and intervention protocols, alongside full
disclosure of the outcome measures used
- Use of validated tools (COPM, FIM, BDI-II) aligned with PD research standards
- Intervention was tailored to the participant’s self-selected goals
- Intervention was conducted in the participant’s home, enhancing ecological validity
- Discussed potential confounding factors (depression’s impact on outcomes)
- Acknowledged study limitations

Limitations

- Single-case design limits applicability to broader PD populations

- Did not clearly define inclusion and exclusion criteria
- Ethnicity and cultural background were not reported, despite evidence that these
factors can influence rehabilitation outcomes and coping strategies in PD (Aamodt,
Willis and Dahodwala, 2023).
- The same therapist delivered and assessed the intervention, risking performance
bias
- No thematic analysis or subjective interpretation of experiences
- The absence of a control group made it impossible to isolate the effects of CO-OP
from natural disease progression, placebo effects, or the impact of social
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 interaction during sessions
- Insufficient to evaluate long-term efficacy, as follow-up was only at one month
- No discussion of participant adherence or environmental factors affecting follow-up
- Harm or adverse events were not discussed

Relevance
- Results showed that CO-OP improved functional independence, occupational
performance and satisfaction
- Results demonstrated short-term benefits but highlight the need for larger trials to
confirm efficacy, particularly in addressing depression and cognitive decline

Table 5: Davies et al. (2025)

Title
Cognitive Orientation to Daily Occupational Performance (CO-OP) in Parkinson’s:
Randomized Trial Findings

Method
RCT

Aim
To explore the feasibility and efficacy of CO-OP for improving QoL, functional
performance, goal attainment and self-efficacy in people with Parkinson’s disease
(PwPD)

Sample
- 20 PwPD (11 female, 9 male) from Greater Brisbane, Australia
- Community-dwelling, independent in daily living

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 Interventions & Duration
- CO-OP (n=11) (20 one-hour sessions over 10 weeks targeting three goals)
- WLC (n=9) (0 sessions over 10 weeks)

Findings
- High adherence (82%), homework completion (91%), and acceptability
(effort/enjoyment ratings ≥3/5)
- Primary Outcomes: CO-OP superior to control on COPM performance/satisfaction
and Performance Quality Rating Scale (PQRS) (*p* < .001), but not GAS
- Secondary Outcomes: No significant improvements in cognitive/functional status or
QoL; self-efficacy improved
- Gains in untrained goals (PQRS/COPM satisfaction) but not maintained at follow-up

Strengths
- Ethical approved document
- Informed consent obtained; participant rights protected
- Demographic characteristics documented
- Clearly defined inclusion and exclusion criteria
- Transparency was prioritised through adherence to CONSORT guidelines and pre-
registration in a clinical trials database
- Study design was rigorous, featuring an assessor-masked, parallel-group RCT with
intention-to-treat analysis, which minimises bias and strengthens internal validity
- Use of multiple outcome measures (COPM, PQRS, GAS) to assess goal attainment
from different perspectives (participant, therapist, and masked assessor) enhances
the robustness of the findings
- Intervention was tailored to the participant’s self-selected goals
- P-values reported
- No dropouts occurred post-randomization
- Demonstrated adaptability by documenting and adjusting for COVID-19-related
disruptions, ensuring continuity despite pandemic challenges
- Statistical rigor was maintained through methods such as multiple imputation for
missing data and controlling for baseline anxiety

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 - Acknowledged study limitations

Limitations
- Small Sample (n=20)
- Sample was homogeneous, limited to independent, highly educated and
community-dwelling individuals with mild to moderate PD
- Reliance on convenience sampling may have introduced selection bias, as
participants were recruited through PD advocacy groups and word of mouth,
potentially excluding those with greater disability or lower socioeconomic status
- The same therapist delivered and assessed the intervention, risking performance
bias
- Participants/therapists unblinded; convenience sampling risks selection bias
- No long-term data for control group; maintenance of gains unclear
- Harm or adverse events were not discussed

Relevance
- Demonstrated CO-OP is feasible and potentially beneficial on occupational
performance, satisfaction, and trained and untrained goals in PwPD
- Supports further large-scale trials but highlights need to address secondary
outcomes (QoL)

Table 6: Wolf et al. (2016)

Title
Combined Cognitive-Strategy and Task-Specific Training Affects Cognition and
Upper-Extremity Function in Subacute Stroke: An Exploratory Randomized
Controlled Trial

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 Method
Single-blind, exploratory RCT

Aim
To estimate the effect of CO–OP vs. usual occupational therapy on upper-extremity
movement, cognitive flexibility, and stroke impact in individuals <3 months post-
stroke

Sample
Adults with ischemic stroke referred for outpatient occupational therapy within 3
months post-stroke
Excluded severe aphasia, cognitive impairment, prior neurological/psychiatric
conditions
Final Sample: 35 randomized (26 completed intervention). Stratified by site (St.
Louis: 20; Toronto: 15). Demographics: Mean age ~54–57 years; mixed ethnicity;
majority right-handed

Interventions & Duration

CO–OP Group: Client-centred, strategy-based training (Goal–Plan–Do–Check) for 10
sessions + optional usual care
Usual Care: Functional and component-based training (e.g., dressing, grasping) by
site therapists
Duration: Variable sessions (mean ~10–17 hours), with follow-up at 3 months post-
intervention

Findings
CO–OP showed medium-to-large effects over usual care on:
- Stroke Impact Scale (SIS): Recovery (large effect), Hand Function (medium effect)
- Cognitive flexibility (D–KEFS Trail Making): Medium effect maintained at 3 months
- Upper-extremity function (ARAT): Small-medium effect post-intervention
- Self-reported performance (COPM) and objective performance (PQRS) improved

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significantly in CO–OP group

Strengths
- Ethical approved document
- Informed consent obtained; participant rights protected
- Demographic characteristics documented
- Clearly defined inclusion and exclusion criteria
- Confidentiality was maintained through blinded raters and anonymised data
handling
- A CONSORT diagram clarified participant flow, and detailed protocols
- Stratified randomisation by site to control geographic variability
- Intervention was tailored to the participant’s self-selected goals with the use of
COPM
- COPM interviews were conducted by blinded occupational therapists, preventing
bias in goal selection
- Standardised, validated tools (e.g., ARAT, D–KEFS) strengthened measurement
reliability
- Independent raters, trained for competency, reduced measurement bias in
outcomes like PQRS and ARAT
- Acknowledged several limitations

Limitations
- Small sample (*n* = 35 randomised, 26 completers) and high attrition (26% dropout)
- Excluded individuals with severe aphasia/cognitive impairment narrowed
applicability to milder stroke cases
- Usual-care content lacked standardisation, and CO–OP fidelity was not monitored,
raising questions about intervention consistency
- A 3-month follow-up was insufficient to assess long-term efficacy or sustainability of
effects
- Self-reported outcomes were vulnerable to recall bias
- CO–OP participants received additional usual care post-intervention, which
confounded the attribution of the impact
- No intention-to-treat analysis was conducted, and effect sizes (Cohen’s *d*) in small

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 samples may overestimate clinical significance
- Lack of robustness in handling missing data
- Harm or adverse events were not discussed

Relevance
- Directly compared top-down (CO–OP) vs. bottom-up (usual care) approaches
- Demonstrated CO–OP’s potential to improve both occupational
performance and underlying impairments (e.g., cognition, motor function),
challenging traditional impairment-focused rehab
- Highlighted the need for further RCTs with larger samples to confirm efficacy and
long-term benefits

Table 7: Saeidi Borujeni et al. (2023)

Title
Cognitive orientation to daily occupational performance approach in people with
multiple sclerosis: A pilot study

Method
Pre-post quasi-experimental design with no control group

Aim
To examine the effects of CO-OP on fatigue, quality of life, occupational
performance, and satisfaction in MS patients, and assess transferability of learnt
strategies to untrained goals

Sample
Initial Sample: 10 Iranian adults with MS

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Excluded 14 candidates due to the Expanded Disability Status Scale (EDSS) range.
Final Sample: 6 completed the study (3 dropped out due to personal reasons, 1 due
to disease relapse)
Demographics: Mean age ~35.3 years; 4 female, 2 male

Interventions & Duration

10 individualised CO-OP sessions (twice/week for 5 weeks), held in participants’
homes. Sessions focused on client-selected goals using the Goal-Plan-Do-Check
framework. 1–2 pre-sessions for goal-setting

Findings
- Trained goals: 12/18 goals showed ≥2-point improvement in performance; 13/18 in
satisfaction.
- Untrained goals: 3/6 goals improved in performance; 4/6 in satisfaction.
- Significant improvements in COPM (performance/satisfaction: *p=0.003*), Fatigue
Impact Scale (FIS) (*p=0.030*), and Multiple Sclerosis Impact Scale (MSIS)
(*p=0.009*).
- Improvements maintained at 3-month follow-up.

Strengths
- Ethical approved document
- Informed consent obtained; participant rights protected
- Clearly defined inclusion and exclusion criteria
- Exemplified transparency through detailed documentation of the participant’s
medical history, duration of symptoms onset, marital status, employment status, and
significant others and caregivers who lived with the participants
- Data anonymisation implied through use of participant numbers only
- Explicit harm avoidance protocols
- Provideed a clear neurocognitive framework for why CO-OP might benefit MS
patients
- Intervention was tailored to the participant’s self-selected goals with the use of
COPM

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- Intervention was conducted in the participant’s home, enhancing ecological validity
- Detailed methodology, including session structure and goal-setting processes
- Use of validated outcome measures (COPM, FIS, MSIS, MoCA, and EDSS)
- P-values reported
- Acknowledged several limitations

Limitations
- Small sample (n=6) and high attrition (40% dropout)
- The restrictive inclusion criteria (EDSS 3.5–5, MoCA >26) excluded individuals with
severe disability or cognitive impairment
- The absence of a control group made it impossible to isolate the effects of CO-OP
from natural disease progression, placebo effects, or the impact of social
interaction during sessions
- The COVID-19 pandemic’s influence on participation was not thoroughly addressed
- A 3-month follow-up was insufficient to assess long-term efficacy or sustainability of
effects
- The study’s cultural context (Iranian participants) may limit transferability to other
settings
- No qualitative feedback from participants on barriers to strategy use in daily life
- No intention-to-treat analysis was conducted
- Risk of bias due to lack of blinding
- No discussion on how attrition may have biased results
- No analysis examines differences between successful vs. unsuccessful transfer
cases

Relevance
- Directly addressed CO-OP’s efficacy in improving occupational performance,
fatigue, and QoL in MS
- Supports feasibility of CO-OP for MS but highlights need for larger RCTs

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Table 8: Ahn et al. (2017)

Title
Comparison of Cognitive Orientation to daily Occupational Performance and
conventional occupational therapy on occupational performance in individuals with
stroke: A randomized controlled trial

Method
Single-blind RCT

Aim
To investigate the effects of the CO-OP approach on occupational performance,
generalisation, and transfer of skills in individuals with chronic hemiparetic stroke
compared to conventional occupational therapy

Sample
- 43 participants (20 experimental, 23 control) with chronic hemiparetic stroke;
MMSE-K ≥19; community-dwelling; able to communicate verbally
- Homogeneous groups at baseline

Interventions & Duration

- Experimental Group: CO-OP approach (client-driven goals, utilised Goal-Plan-Do-
Check strategy)
- Control Group: Conventional OT (therapist-directed, component-based)
- Duration: 12 sessions over 5 weeks

Findings
- CO-OP group showed significant improvements in COPM and PQRS scores for
both trained and non-trained tasks compared to control (p < 0.001)
- Clinically meaningful improvement (≥2 points) in COPM for 65% of CO-OP group
vs. 13% control

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- Transfer of skills to untrained tasks observed in CO-OP group

Strengths
- Ethical approved document
- Informed consent obtained; participant rights protected
- Clearly defined inclusion and exclusion criteria
- Minimised selection bias through participant randomisation
- Utilised single-blinded assessors to reduce measurement bias
- Clearly defined inclusion and exclusion criteria
- Use of validated tools (COPM, PQRS)
- P-values reported
- Extensive baseline testing ensured proper group comparability and allowed readers
to assess sample representativeness
- Detailed descriptions of the CO-OP intervention and conventional occupational
therapy protocols
- Transparently noted that conventional occupational therapy also showed some
(albeit smaller) gains, avoiding overclaiming of results
- Statistically robust analyses (e.g., independent and paired t-tests) support the
validity of the results
- Acknowledged several limitations

Limitations
- Small sample (n=43)
- Insufficient demographic data
- Restricted to South Korean stroke survivors with intact cognition
- All participants had intact cognition (MMSE-K ≥19), but no breakdown of outcomes
by stroke severity, age subgroups, or motor function was provided
- Recruitment from outpatient centres may have introduced selection bias
- Dropouts were clearly noted in the CONSORT flow diagram (Figure 1), though
details were sparse
- No follow-up post-intervention; long-term efficacy unknown
- No intention-to-treat analysis was conducted
- No qualitative data on participants’ experiences was collected, which could

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 contextualise quantitative results

Relevance
- Directly addressed the research question by demonstrating CO-OP’s superiority
over conventional occupational therapy in improving short-term occupational
performance and transfer of skills

3.2 Synthesis of findings

In each of the selected studies, the findings provide a robust exploration of CO-OP
for adults with neurological conditions, though they vary in design, sample
characteristics, and methodological rigor. Collectively, they highlight CO-OP’s
potential in improving occupational performance, QoL, and satisfaction, while also
revealing several limitations. The findings also brought out the realisation that the
approach entails the patients or the treatment goals focusing and consequently, is
very effective in addressing the patient’s individualistic challenge as well as the
accomplishments of the functional goals that relate to such challenges.

All studies targeted adults with mild-to-moderate neurological conditions, excluding

severe cognitive impairment. Client-centred goal-setting via COPM was universal.

The reviewed studies demonstrated strong adherence to ethical standards, including

institutional approvals, informed consent, and confidentiality protections. However,
only Davies et al. (2025) explicitly addressed adverse events, while others omitted
this discussion. Methodologically, the studies employed heterogeneous designs,
ranging from single-case study to RCTs and quasi-experimental pilot study. The
RCTs (Davies et al., 2025; Wolf et al., 2016; Ahn et al., 2017), considered the gold
standard for providing higher evidence levels due to controlled designs and blinded
assessments, whereas single-case and pilot studies (Taheri et al., 2023; Saeidi

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Borujeni et al., 2023) offered granular insights into individualised interventions but
lacked generalisability (Burns, Chung and Rohrich, 2011).

3.3 Thematic Analysis

Thematic analysis was chosen to extract patterns and features from the analysed
literature. This entailed coding data from the studies to come up with themes that
capture the effectiveness, as well as the difficulties, of the CO-OP approach. Based
on the identified themes, this is a comprehensive understanding of how the approach
works and its application to occupational therapy. The themes are presented not only
as the potential advantages of CO-OP in enhancing the well-being of adults with
neurological conditions but also as the directions for further research and
development.

Theme 1: Effectiveness of the CO-OP Approach

The first major theme focuses on understanding the extent to which the CO-OP
approach successfully enhances occupational performance for the participants.
According to the literature, there are always positive gains in occupational
performance and satisfaction among the participants in short-term. For example, Ahn
et al. (2017) reported a 65% rate of clinically meaningful COPM improvements in
stroke patients post-intervention, while Saeidi Borujeni et al. (2023) documented
significant reductions in fatigue and MSIS scores. These findings align with CO-OP’s
theoretical foundation, which posits that cognitive strategy training enhances
immediate problem-solving and task mastery (Polatajko et al., 2001). Nevertheless,
sustainability emerged as a critical concern. Taheri et al. (2023) observed a
regression in cooking performance at one-month follow-up, and Wolf et al. (2016)
noted diminished upper-extremity gains by three months. The data imply that CO-OP
effectively manages immediate deficits but may lack lasting impact without
complementary strategies like periodic refreshers or contextual modifications. Maier,
Ballester and Verschure (2019) highlighted this gap when reviewing interventions
that focus solely on cognitive-motor training.

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Theme 2: Personalisation of Intervention

Personalisation emerged as a key theme, with studies emphasising the tailored and
client-centred nature of the CO-OP approach. This aspect of the intervention
ensures that therapeutic goals align with individual needs and preferences, leading
to higher engagement and satisfaction among participants (Mroz et al., 2015). All
studies prioritised client-selected goals which not only improved task-specific
performance but also enhanced perceived satisfaction and autonomy. This aligns
with CO-OP’s theoretical roots in self-efficacy and participatory approach (Polatajko
et al., 2001). Such personalisation underscores the CO-OP approach's adaptability
to the unique needs of each individual, making it an essential component of
successful occupational therapy interventions. However, the lack of qualitative
insights into participants’ experiences across studies restricts understanding of how
personalisation intersects with psychosocial or cultural contexts.

Theme 3: Challenges and Barriers to Implementation

Despite its benefits, the CO-OP approach faces challenges and barriers that hinder
its widespread implementation. Limited accessibility, insufficient therapist training,
and resource constraints were frequently mentioned across the reviewed studies
(Zaman, Ghahari and McColl, 2021; Zarshenas et al., 2020). For instance, high costs
of delivering individualised care limit the approach's feasibility in low-resource
settings (van Zyl et al., 2021). Recommendations to address these challenges
include expanding training programmes for occupational therapists and developing
cost-effective models for delivering CO-OP interventions as well as integrating
technology-based solutions, such as virtual therapy sessions, to enhance
accessibility (BACP, 2019; Hand, Li and Mroz, 2022). These findings emphasise the
need for systemic changes to ensure that the benefits of CO-OP reach a broader
population.

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4. Discussion

4.1 Interpretation of Findings

The synthesised themes derived from the literature collectively address the research
question by explaining the role of the CO-OP approach in neurological
rehabilitation. These themes are interpreted here through novel theoretical and
clinical lenses, avoiding redundancy with prior analyses, to develop a deeper
understanding of CO-OP’s potential and limitations.

Theme 1: Effectiveness of the CO-OP Approach

The effectiveness of CO-OP extends beyond immediate functional gains to its

unique alignment with principles of neuroplasticity and metacognition. Neuroplasticity

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theory posits that repetitive, goal-directed activities strengthen synaptic connections,
particularly in prefrontal and parietal regions responsible for executive function and
motor planning (Kleim and Jones, 2008). CO-OP’s emphasis on cognitive strategy
use, such as self-monitoring and error correction, activates these neural networks,
promoting adaptive reorganization in brains damaged by stroke or
neurodegenerative diseases. As an example, when a patient with MS practices
problem-solving during meal preparation, the cognitive effort required to plan and
adjust movements may enhance cortical remapping, compensating for
demyelination-related deficits (Straudi and Basaglia, 2017). CO-OP’s reliance on
neuroplasticity explains its initial success but also its potential decline in progressive
conditions like PD or MS. Studies indicate that without ongoing reinforcement, neural
adaptations fostered by CO-OP may diminish as neurodegeneration advances
(Cramer et al., 2011). In PD, dopamine depletion gradually erodes executive
function, undermining clients’ ability to apply learnt strategies independently
(Ramesh and Perera, 2023).

Metacognition, the awareness and regulation of one’s cognitive processes, emerges

as a critical mediator of CO-OP’s efficacy (Rivers, Dunlosky and Persky, 2019).
Individuals with TBI often exhibit anosognosia (impaired self-awareness), leading to
inconsistent strategy use post-therapy (Ownsworth et al., 2006). Thus,
integrating errorless learning techniques can minimise mistakes during skill
acquisition and improve retention in such populations (Hilger, 2022).

Also, CO-OP’s effectiveness aligns with Bandura’s self-efficacy theory, where

mastery experiences (e.g., achieving client-selected goals) enhance confidence and
functional independence (Bandura, 1977). The intervention’s structured “Goal-Plan-
Do-Check” framework provides repeated opportunities for mastery, fostering a sense
of agency (Schwartz et al., 2020). However, the sustainability of these gains
emerged as a critical limitation. The transient nature of CO-OP’s benefits points out
the need for adjunct strategies, such as booster sessions or environmental
modifications, to reinforce cognitive strategies in daily contexts (Curtiss et al., 2021).
Additionally, the lack of long-term follow-up in most studies (e.g., Ahn et al., 2017)
limits conclusions about CO-OP’s durability, highlighting a gap in current evidence.
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Theme 2: Personalisation of Intervention

Personalisation in CO-OP transcends client-centred goal-setting to encompass

cultural and contextual adaptability. The ecological validity of interventions, known as
the degree to which therapeutic activities reflect the real world, is critical in
neurological rehabilitation, where environmental barriers (e.g., cluttered homes,
social stigma) often undermine progress (Andrade, 2018). CO-OP’s flexibility allows
therapists to simulate these contexts during sessions, such as role-playing social
interactions or practicing medication management in a noisy kitchen. This aligns with
Bronfenbrenner’s ecological systems theory (1979), which emphasises the interplay
between human development and their environments.

Cultural competence further refines personalisation. In collectivist societies, where

familial roles heavily influence self-concept, CO-OP goals might prioritise communal
activities (e.g., cooking for family gatherings) over individual tasks, as these activities
reinforce social identity and emotional wellbeing (Powers, 2013). To illustrate, in
many Asian cultures, the ability to prepare ancestral dishes or care for grandchildren
may hold greater meaning than mastering personal self-care tasks, as these roles
validate one's position within the intergenerational family structure (Chen, Liu and
Mair, 2011). Conversely, in individualistic cultures, goals may focus on personal
independence, reflecting Western values of autonomy and self-sufficiency (Powers,
2013). Therefore, the need for culturally informed adaptations is paramount when
delivering CO-OP interventions, as therapeutic success hinges on aligning
rehabilitation strategies with patients' deeply held values, social roles, and
environmental contexts.

Theme 3: Challenges and Barriers to Implementation

Systemic barriers to CO-OP adoption raise the broader question of its efficacy in
treating adults with neurological conditions. The Social-Ecological Model offers a
framework for understanding these barriers. It emphasises that effective
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interventions must navigate multiple interconnected systems (Caperon, Saville and
Ahern, 2022; Kilanowski, 2017). At the institutional level, resource limitations in
healthcare settings, such as time constraints and funding shortages, directly impede
the adoption of CO-OP, which demands individualised sessions and extended client
engagement.

Therapist competency emerges as another pivotal factor. The Career Development

Framework in occupational therapy highlight that mastering CO-OP’s client-centred,
strategy-based approach requires specialized training beyond traditional motor
rehabilitation (RCOT, 2022). Without standardised training programs, variability in
fidelity and delivery diminishes intervention consistency, potentially compromising
outcomes. Addressing this competency gap requires institutional investment in
training infrastructure and clearer clinical guidelines to support sustained use of CO-
OP in adult neurological rehabilitation.

4.2 Limitations

The current body of evidence on CO-OP’s efficacy in neurological populations

has several limitations that temper the strength of conclusions. Foremost, the
scarcity of high-quality research in this field restricts the findings' generalisability and
emphasises that this field is still emerging. Such a narrow evidence base limits
robust meta-analyses and highlights the need for further large-scale trials to validate
CO-OP’s role in neurorehabilitation. A prominent gap across studies was the limited
examination of long-term efficacy. Only Saeidi Borujeni et al. (2023) and Wolf et al.
(2016) included follow-ups. Both studies had three-month follow-ups, which is
insufficient to evaluate CO-OP’s sustainability in chronic or progressive neurological
conditions, yet both noted declining gains. In particular, for progressive disorders like
PD and MS, this raises questions about CO-OP’s role in chronic neurological
management. Another gap lies in the homogeneity of study populations. Most
participants had mild-to-moderate impairments, with exclusion criteria often omitting
individuals with severe cognitive deficits or comorbidities. This limits CO-OP’s
applicability to higher-functioning individuals, neglecting those with advanced
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disease who may benefit most from compensatory strategies. In spite of the sound
reasoning and valid method used, it can be argued that sample size is relatively
small among all studies. Therefore, the test may not have a sufficient equivalent
statistical power and increase the risk of Type II errors (Serdar et al., 2020).
Furthermore, limitations to the study include proximal factors that may have affected
the results including participants’ cognitive abilities, severity of the illness, or
availability and use of other supportive systems. These limitations limit the
generalisability of the results and, when making transferable conclusions, need to be
taken into consideration.

4.3 Implications

The conclusion drawn from this research provides tremendous practical relevance to
occupational therapy especially, while developing intervention strategies. The
presented CO-OP approach, based on the idea of individual goals and problems
solving in the process of interaction between practitioner and client, can be
considered as an effective strategy for the skills development, both motor and
cognitive. Practitioner can apply it in practice by stressing that every client needs to
be provided with individualized treatment care plan. Ideally from the perspective of
occupational science this work adds knowledge on how occupation-promoting
interventions affect the QoL of adults with neurological conditions. The technique of
the CO-OP is therefore more enriched by the combination of cognitive and motor
aspects, which support the biopsychosocial model in occupational therapy (Gentry et
al., 2018).

Further research should centre in the identified limitations of the present study; most
importantly in relation to the sample size and overall generalisability, whilst
prioritizing longitudinal studies to evaluate the sustainability of the CO-OP approach.
Future investigations should explore how CO-OP interacts with neuroplasticity
mechanisms, particularly in conditions with fluctuating cognitive reserves, and
healthcare systems should allocate funding for large-scale RCTs to establish its
cost-effectiveness and scalability. Additionally, expanding research into CO-OP’s

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application across diverse populations and neurological conditions, including those
not yet studied, would provide further insights into the flexibility and adaptability of
the approach, while studies examining its integration with complementary therapies,
such as physical therapy or cognitive behavioural therapy, may reveal synergies to
enhance outcomes. Subsequent research should also refine the CO-OP model by
investigating possible moderation effects of various delivery modes of early
healthcare intervention, such as differences between clinic-based and home-based
delivery modes, to optimize implementation across healthcare settings.
Interdisciplinary collaboration, involving occupational therapists, physiotherapists,
and psychologists, should be experimentally tested to assess the approach’s
effectiveness when implemented into team care. In various contexts, subsequent
investigations of the intervention will further elaborate CO-OP, which will help the
lives of individuals suffering from neurological conditions improve.

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5. Conclusion

To summarise, this literature review aimed to answer the research question ‘How
effective is the use of Cognitive Orientation to Daily Occupational Performance
approach in improving occupational performance and quality of life in adults with
neurological conditions?’ through a systematic analysis of five critically appraised
studies.

Findings demonstrated CO-OP’s potential to enhance occupational performance and

quality of life via client-centred cognitive strategies, with short-term improvements in
functional independence and goal attainment. However, long-term sustainability in
progressive conditions remains inconsistent. One study demonstrated CO-OP’s
superiority over conventional therapy, yet broader conclusions are limited by
methodological constraints, including small sample sizes and a lack of long-term
follow-up. Three key themes emerged, highlighting CO-OP’s strengths in
personalisation and neurorehabilitation, alongside challenges in implementation and
accessibility. These insights advocate for integrating CO-OP into neurorehabilitation
practice while addressing implementation challenges to optimise its evidence-based
application.

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